Provider Demographics
NPI:1265762363
Name:GLENN G DESHAW OD PA
Entity type:Organization
Organization Name:GLENN G DESHAW OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-485-0700
Mailing Address - Street 1:2636 W WALNUT ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-6441
Mailing Address - Country:US
Mailing Address - Phone:972-485-0700
Mailing Address - Fax:972-485-0702
Practice Address - Street 1:2636 W WALNUT ST
Practice Address - Street 2:STE. 200
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6441
Practice Address - Country:US
Practice Address - Phone:972-485-0700
Practice Address - Fax:972-485-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5678Medicare PIN